IM Essentials

Question 1

What are risk factors for seizure recurrence after a first seizure?

Answer 1

The risk of recurrence is greatest in patients who have status epilepticus on presentation, an identifiable underlying neurologic cause, or abnormal results on an electroencephalogram (EEG). Patients with a partial seizure who are age 65 years or older or who have a family history of epilepsy may also be in a higher-risk category.

Question 2

What does MRI of brain in FTD show?

Answer 2

Magnetic resonance imaging of the brain shows disproportionate atrophy of the frontal and anterior temporal regions.

Question 3

What is the main modifiable RF for rheumatoid arthritis?

Answer 3

The duration and intensity of smoking correlate with the risk of developing rheumatoid arthritis.

Question 4

What should you do once the diagnosis of myasthenia gravis is confirmed?

Answer 4

CT of the chest to rule out thymoma as this is present in 15% of MG pts.

Question 5

What is the characteristic finding of fibromuscular dysplasia on renal artery angiogram?

Answer 5

On angiogram, the characteristic finding of fibromuscular dysplasia is the “string of beads” appearance of the involved artery

Question 6

Why can hypercalcemia lead to dehydration?

Answer 6

High calcium levels impair the ability of the nephron to concentrate urine, which results in inappropriate water loss from the kidney.

Question 7

When is bariatric surgery for weight reduction indicated?

Answer 7

Bariatric surgery is recommended as a treatment option for patients who have been unable to maintain weight loss with diet and exercise with or without drug therapy with class III obesity, defined as patients who have a body mass index (BMI) ≥40, or those with BMIs of 35 to 39.9 (class II) who have obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea.

Question 8

What is lorcaserin and what is it used for?

Answer 8

It is a serotonin 2C agonist and is used for weight loss w/ similar efficacy as orlistat although it lacks long term safety data.

Avoid using in combo w/ other serotonergic drugs like SSRIs.

Question 9

What is the definition of subclinical hypothyroidism?

Answer 9

A serum thyroid-stimulating hormone (TSH) level greater than the reference range, with a concomitant serum free thyroxine (T4) level in the reference range. Patients typically have mild or no symptoms of hypothyroidism.

Question 10

What is the optimal glucose management approach for an a severely ill (i.e. ICU) pt?

Answer 10

The optimal glucose management for this critically ill patient is an insulin drip with a target plasma glucose level of 140-200 mg/dL (7.8-11.1 mmol/L).

Question 11

What classifies moderately persistent asthma per guidelines? What do guidelines recommend for “step-up” treatment at this point?

Answer 11

Daily symptoms of asthma and nocturnal awakenings more than once per week

Guidelines recommend the addition of a long-acting β2-agonist to medium-dose corticosteroids in patients with moderate persistent asthma.

Question 12

What is the appropriate follow up for patients w/ average risk prostate cancer who achieve remission after radiation therapy?

Answer 12

Patients with average-risk prostate cancer who achieve remission after radiation therapy should receive follow-up with serial digital rectal examinations and serum PSA measurement every 6 to 12 months.

Question 13

What is Asherman syndrome?

Answer 13

It is intrauterine adhesions. Asherman syndrome is caused by endometrial scarring after a uterine procedure (usually repeated dilation and curettage) and should be considered in any woman with amenorrhea and past exposure to uterine instrumentation.

Question 14

What is Lemierre syndrome? When should you suspect it?

Answer 14

It is septic thrombus of the jugular vein. The diagnosis of septic thrombosis of the jugular vein (Lemierre syndrome) should be suspected in patients with pharyngitis, persistent fever, neck pain, and septic pulmonary emboli.

Question 15

What sorts of medications should be avoided in HFpEF?

Answer 15

Those that decrease preload.

Question 16

What malignancies are Henoch-Schönlein purpura associated with?

Answer 16

Onset of Henoch-Schönlein purpura may occur in adults and can be associated with solid tumors or the myelodysplastic syndrome.

Question 17

When is DEXA scanning for osteoporosis screening recommended in women?

Answer 17

The U.S. Preventive Services Task Force recommends screening for osteoporosis with DEXA in all women age 65 years or older and also in younger women with an elevated fracture risk.

Question 18

What are the modifiable risk factors for osteoporosis?

Answer 18

Among the modifiable risk factors for osteoporosis are adequate amounts of both calcium and vitamin D, regular exercise, cessation of cigarette smoking, and avoidance of alcohol abuse.

Question 19

What is the best treatment for asymptomatic pancreatic pseudocysts following pancreatitis?

Answer 19

Asymptomatic pancreatic pseudocysts following acute pancreatitis typically resolve spontaneously and do not require treatment.

Question 20

When is EPO indicated in CKD?

Answer 20

ESAs are indicated for patients with CKD who have hemoglobin levels less than 10 g/dL (100 g/L), but other causes of anemia, including iron deficiency, hemoglobinopathies, vitamin B12 deficiency, and gastrointestinal blood loss, should be considered before beginning this therapy.

Don’t initiate ESAs in Hgb > 12g/dL as EPO is associated w/ increased CV outcomes.

Question 21

What are the criteria for diagnosing osteoarthritis?

Answer 21

Knee osteoarthritis can be diagnosed if knee pain is accompanied by at least three of the following features: age greater than 50 years, stiffness lasting less than 30 minutes, crepitus, bone tenderness, bone enlargement, and no palpable warmth. These criteria are 95% sensitive and 69% specific for diagnosis.

Question 22

What are effective treatments for acute gout attacks?

Answer 22

Effective treatment of acute attacks of gout involves therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, or colchicine.

Question 23

True or false, eosinophilia can be seen in adrenal insufficiency?

Answer 23

True!

Question 24

What are the screening guidelines for cervical cancer?

Answer 24

Although the typical Pap smear screening interval for women ages 21 to 65 years is every 3 years, the USPSTF now recommends that women 30 to 65 years old may have a Pap smear with HPV testing every 5 years if they wish to extend the time in between tests

Question 25

What are the screening guidelines for osteoporosis?

Answer 25

The USPSTF recommends routine screening for osteoporosis in all women aged ≥65 years and in younger women who are at increased risk for osteoporotic fractures.

Women at increased risk for low bone density include those with a smoking history, physical inactivity, secondary osteoporosis, prolonged glucocorticoid use, prolonged hyperthyroidism, celiac disease, a family history of osteoporosis, and inadequate calcium intake.

Question 26

How do likelihood ratio results correlate to the increase or decrease in likelihood of a disease being present?

Answer 26

LR(+) values of 2, 5, and 10 correspond to an increase in disease probability by 15%, 30%, and 45%, respectively; LR(-) values of 0.5, 0.2, and 0.1 correspond to a decrease in disease probability by 15%, 30%, and 45%, respectively.

(Note this is general rule of thumb type logic)

Question 27

How does the pain of pes anserine bursitis present?

Answer 27

The pain of pes anserine bursitis is typically located along the anteromedial aspect of the proximal tibia distal to the joint line of the knee and characteristically worsens with stair climbing and at night.

Question 28

True or false, the diagnosis of ITP is made by anti-platelet antibody testing?

Answer 28

Flase! Antiplatelet antibody testing is found to have little predictive value in the diagnosis of ITP and is not recommended.

Question 29

Why is initial urate lowering therapy for gout prevention in people who have had recurrent attacks both allopurinol and colchicine?

Answer 29

Because the addition of urate-lowering therapy transiently increases the risk for acute gout attacks for at least 3 to 6 months; accordingly, prophylaxis with an anti-inflammatory agent such as colchicine, at least during that period, is indicated concurrent with urate-lowering therapy.

Question 30

What is the pathophysiology of hepatorenal syndrome?

Answer 30

Intense renal vasoconstriction (due to portal hypertension) leads to a syndrome of acute kidney dysfunction characterized by increased renal sodium avidity, a relatively normal urine sediment, and oliguria in some patients.

Question 31

What are things that may precipitate hepatorenal syndrome?

Answer 31

Spontaneous bacterial peritonitis, vigorous diuretic therapy, paracentesis without volume expansion, and gastrointestinal bleeding also may precipitate hepatorenal syndrome.

Question 32

What is the blood pressure cut off for tPA in stroke?

Answer 32

Prior to tPA BP must be less than 185/110. After thrombolysis, the target blood pressure is less than 180/105 mm Hg for at least 24 hours.

Question 33

What is a typical presentation of constrictive pericarditis?

Answer 33

Dyspnea, pedal edema, clear lung fields, and jugular vein engorgement with inspiration (aka Kussmaul sign) raise clinical suspicion for constrictive pericarditis.

Question 34

What is the echocardiogram finding that indicates ventricular interdependence (can be seen in constrictive pericarditis)?

Answer 34

Diastolic filling of one ventricular chamber that impedes that of the other, as may be manifested by a to-and-fro diastolic motion of the ventricular septum

Question 35

What are secondary causes of dyslipidemia and when should they be considered?

Answer 35

In patients with hyperlipidemia that is refractory to medical therapy, secondary causes, including hypothyroidism, diabetes mellitus, nephrotic syndrome, and obstructive liver disease, should be considered.

Question 36

What is the treatment of diffuse large B cell non-Hodgkin’s lymphoma?

Answer 36

Treatment for all patients with large B-cell NHL includes chemotherapy (usually cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab [R-CHOP]) and immunotherapy with rituximab. Radiation therapy is used after a shorter course of chemoimmunotherapy in patients with localized or bulky disease

Question 37

True or false, patients w/ systolic HF should be treated w/ a B-blocker?

Answer 37

True! Patients with systolic heart failure should be treated with a β-blocker, regardless of symptom status, including heart failure that is asymptomatic or mildly symptomatic.

Question 38

What are the characteristics of type 1 RTA?

Answer 38

Hypokalemic distal (type 1) renal tubular acidosis is characterized by normal anion gap metabolic acidosis, hypokalemia, a urine pH greater than 6.0, and nephrocalcinosis.

Question 39

What is Gitelman syndrome?

Answer 39

Gitelman syndrome is an autosomal recessive syndrome characterized by hypokalemic metabolic alkalosis. The defect is due to inactivating mutations in the gene for the thiazide-sensitive sodium chloride cotransporter in the distal convoluted tubule, and the electrolyte profile is analogous to that induced by thiazide diuretics.

Question 40

What are the manifestations of tumor lysis syndrome?

Answer 40

The manifestations of TLS include hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, acute kidney injury, and disseminated intravascular coagulation.

Question 41

What is the equation for the corrected serum bicarb and when is it used?

Answer 41

Corrected [HCO3] = measured [HCO3] + (measured anion gap – 12)

The corrected serum bicarbonate level is calculated to determine if a complicating metabolic disturbance is present. The number is the expected bicarbonate concentration if no other acid-base disturbances are present.

Question 42

What are markers of increased morbidity and mortality from acute pancreatitis?

Answer 42

Increased BUN, serum creatinine, and increased hematocrit. AKA markers of hemoconcentration.

BUN is most accurate for predicting severity.

Question 43

When is treatment of PVCs indicated and what is the best initial therapy?

Answer 43

Suppression of premature ventricular complexes is indicated only in patients with severe and disabling symptoms. In these patients, β-blockers are the safest initial therapy.

Question 44

How is the dx of acute chest syndrome made?

Answer 44

The diagnosis of the acute chest syndrome is established by identifying an infiltrate on chest radiographs that involves at least one lung segment and that is not thought to be due to atelectasis; associated findings include one or more of the following: chest pain; temperature less than 38.3°C (100.9°F); tachypnea, wheezing, cough, or the development of increased work of breathing (such as retractions); and hypoxemia relative to baseline oxygen saturation values.

Question 45

When should anti-osteoporosis therapy be considered/initiated?

Answer 45

Antiosteoporotic therapy should be considered in a patient with low bone mass whose Fracture Risk Assessment Tool (FRAX) risk of major osteoporotic fracture over the next 10 years is 20% or greater or whose risk of hip fracture over the next 10 years is 3% or greater.

Question 46

What is the treatment for lupus nephritis?

Answer 46

Early treatment with high-dose glucocorticoids is indicated for patients with systemic lupus erythematosus and findings strongly suspicious for lupus nephritis.

Question 47

What are the colorectal screening guidelines for for patients with a first-degree relative with colorectal neoplasia at age younger than 60 years or two or more first-degree relatives with colorectal cancer diagnosed at any age.

Answer 47

For these individuals, colonoscopy screening should begin at age 40 years or age 10 years before youngest age at colorectal neoplasia or colorectal cancer diagnosis in the family, whichever is younger.

Question 48

How often should pts w/ UC that extends beyond the rectum receive screening colonoscopy?

Answer 48

Patients with ulcerative colitis with disease extending beyond the rectum should undergo routine surveillance colonoscopy with biopsies every 1 to 2 years beginning 8 to 10 years after diagnosis.

Question 49

What is bitter almond breath a characteristic of?

Answer 49

Inhaled cyanide poisoning (can be seen in people exposed to fumes from burning rubber or plastic).

Question 50

In addition to a rapid neurosurg consult, what is needed for pituitary tumor apoplexy immediate treatment?

Answer 50

In addition to neurosurgical decompression of the pituitary gland, urgent glucocorticoid administration is often necessary in patients with pituitary tumor apoplexy because of acute adrenocorticotropic hormone deficiency.

Question 51

What should you do for a pregnant pt w/ asthma who has uncontrolled sxs w/ medium dose inhaled corticosteroids?

Answer 51

In pregnant patients with asthma, the addition of a long-acting β2-agonist is recommended when symptoms are not controlled with medium-dose inhaled glucocorticoids.

Question 52

What is the most common psychiatric cause of involuntary weight loss?

Answer 52

Depression accounts for 9% to 15% of all cases of involuntary weight loss and is the most common psychiatric cause of involuntary weight loss.

Question 53

Can memantine tx alzheimer’s disease?

Answer 53

Yes! The N-methyl-D-aspartate receptor antagonist memantine is approved by the Food and Drug Administration as first-line treatment of moderate to advanced Alzheimer disease.

Question 54

How do you generally treat prosthetic joint infection?

Answer 54

Treatment of prosthetic joint infection typically involves removal of the infected prosthesis, and is required for late infection or with infection-related dysfunction of the prosthesis, such as loosening.

Question 55

What sort of information prognosticates CLL?

Answer 55

In patients with CLL, the β2-microglobuin level, heavy gene mutational status, and cytogenetics provide independent prognostic information on appropriate follow-up monitoring and time to initiate treatment.

Question 56

How does acral lentiginous melanoma present typically?

Answer 56

Acral lentiginous melanoma presents as an unevenly darkly pigmented patch that most often arises on the palmar, plantar, or subungual surfaces.

Question 57

What is the most common complication of heparin induced thrombocytopenia?

Answer 57

Venous thromboses are the most common complication of heparin-induced thrombocytopenia, but arterial thromboses also occur and can be life-threatening.

Question 58

Do patients who had vaginal hysterectomies due to benign disease still need screening pap smears?

Answer 58

NO!!! Discontinuing routine cervical cancer screening is the most appropriate recommendation in this patient who has had a hysterectomy for benign disease.

Question 59

What is the bicarb compensation in acute respiratory alkalosis?

Answer 59

In acute respiratory alkalosis, for each 10 mm Hg (1.3 kPa) decline in Pco2, the expected decline in the serum bicarbonate level is 2 mEq/L (2 mmol/L).

Question 60

When is the best time to evaluate someone for inherited thrombophilia after a thrombolic event?

Answer 60

Avoid testing for inherited thrombophilias during the acute phase of a venous thromboembolic disease, especially if anticoagulant therapy has already been initiated, since many false-positive test results may occur during this period. Specifically, antithrombin, protein C, protein S, and dysfibrinogenemia testing may be altered during acute thrombotic events and their treatment.

Sounds like a couple weeks into anticoagulation is best.

Question 61

Name 5 foods known to be high in oxalate

Answer 61

rhubarb, peanuts, spinach, beets, and chocolate

Question 62

How quickly does effective HIV therapy suppress viral load?

Answer 62

Suppression of HIV viral load to less than 50 copies/mL should occur by 24 weeks of effective therapy.

Question 63

How does decreased preload (i.e. valsalva) affect the murmur of HOCM? What about increased afterload?

Answer 63

Decreased preload –> accentuates the murmur

Increased afterload –> attenuates the murmur

Question 64

In whom is abx ppx indicated prior to dental work?

Answer 64

Prophylaxis is needed in patients with a prosthetic cardiac valve, a history of infective endocarditis, unrepaired cyanotic congenital heart disease, congenital heart disease repair with prosthetic material or device within the last 6 months, palliative shunts and conduits, or cardiac valvulopathy in cardiac transplant recipients.

Question 65

What is appropriate bicarb compensation for respiratory acidosis?

Answer 65

In respiratory acidosis, the predicted increase in the serum bicarbonate level is calculated as 1 mEq/L (1 mmol/L) for each 10 mm Hg (1.3 kPa) increase in Pco2 (acute) or 4 mEq/L (4 mmol/L) for each 10 mm Hg (1.3 kPa) increase in Pco2 (chronic).

Question 66

Which findings are unique to serotonin syndrome?

Answer 66

Findings unique to serotonin syndrome are shivering, hyperreflexia, myoclonus, and ataxia.

Question 67

What sort of therapy is indicated when RA is not adequately controlled w/ one or more oral disease modifying therapies (DMARDs)?

Answer 67

When adequate control of rheumatoid arthritis is not achieved with one or more oral disease-modifying antirheumatic drugs (DMARDs), the addition of biologic therapy with a tumor necrosis factor α inhibitor is usually indicated.

Question 68

What imaging modality is best for diagnosing kidney stones?

Answer 68

Noncontrast abdominal helical CT is the gold standard for diagnosing kidney stones.

Question 69

How do you diagnose metabolic syndrome?

Answer 69

Metabolic syndrome is diagnosed by the presence of three or more of five abnormalities: increased waist circumference, elevated systolic or diastolic blood pressure, decreased HDL cholesterol level, elevated triglyceride level, and elevated fasting plasma glucose level.

Question 70

How can you distinguish effusion and lobar consolidation of physical exam?

Answer 70

Expect increased tactile fremitus w/ consolidation and decreased w/ effusion.

Question 71

What are the Centor criteria?

Answer 71

The Centor criteria (temperature >38.1°C [100.5°F], tonsillar exudates, and tender cervical lymphadenopathy; absence of cough) predict the likelihood of streptococcal pharyngitis.

Question 72

What is the first line treatment for polycythemia vera?

Answer 72

Asprin and phlebotomy (target Hct is 45%)

Question 73

What is the initial treatment of choice for metastatic prostate cancer?

Answer 73

Androgen deprivation therapy (GnRH agonists and androgen antagonists like flutamide initially)

Question 74

What is zoledronic acid? When is it preferred?

Answer 74

Zoledronic acid is an IV bisphosphonate. It is preferred to oral bisphosphonates like alendronate when pts have esophageal issues like GERD b/c oral agents carry the risk of erosive esophagitis.

Question 75

What is the first line treatment for status epilepticus?

Answer 75

IV lorazepam. Second line agents are valproate and IV phenytoin/fosphenytoin but they are not as preferred b/c they have a slower onset of action.

Question 76

What is the empiric treatment of acute epididymitis in sexually active men < 35 years old?

Answer 76

Empiric treatment for acute epididymitis in sexually active men younger than than 35 years of age consists of ceftriaxone and doxycycline (or azithromycin).

*One exception is MSM who are insertive, swap levofloxacin for doxy/azithro b/c increased chance the infection is caused by an enteric gram negative.

Question 77

What characterizes adult onset Still disease?

Answer 77

Adult-onset Still disease is a systemic inflammatory disorder characterized by quotidian (daily) fever, an evanescent salmon-colored rash, arthritis, multisystem involvement, and markedly elevated serum ferritin levels.

Question 78

How do the following factors affect the levels (and thus interpretation) of BNP?

• Obesity?
• Female sex?
• Kidney Failure?
• Old age?

Answer 78

Obesity will falsely lower levels. Kidney failure, old age and female sex will raise BNP levels.

Question 79

What is the initial treatment of drug-induced dystonic reactions?

Answer 79

Initial treatment of drug-induced dystonic reactions is conservative, starting with withdrawal of the offending agent and then with drug therapy such as benzodiazepines or anticholinergic agents or botulinum injections.